Form 1428-A Request for Waiver of NSF/OPP Medical Requirements - Ant

NATIONAL SCIENCE FOUNDATION
4201 WILSON BOULEVARD
ARLINGTON, VIRGINIA 22230

OFFICE OF POLAR PROGRAMS
703-292-8031

FROM:
TO:

_______________________________________ (Applicant’s name)
Head, Polar Environment, Health and Safety Office
Office of Polar Programs, National Science Foundation

VIA:

(1) (Employer)
(2) Raytheon Polar Services Company (Attn: Medical Staff)

SUBJECT:

Request for Waiver of USAP Medical Screening Criteria

1. I have been informed of the qualifications for assignment or travel to an Antarctic
research or support station, as established in the USAP Medical Screening
Guidelines.
2. I am aware that the USAP qualifications criteria are established to: identify civilian
employees, visitors and military personnel working in support of the U.S. Antarctic
Program (USAP) who are physically qualified and temperamentally adapted for
assignment or travel to Antarctica, and to disqualify those individuals who may
require repeated, prolonged or specialized treatment, whose presence in Antarctica
may endanger his/her own life or safety, and/or the lives or safety of other personnel.
I understand that the criteria established by the USAP apply equally to all U.S. or
foreign visitors to Antarctica who are sponsored by the National Science Foundation.
3. I am aware that medical facilities and capabilities in Antarctica are limited and may
be quite distant from working or research sites. I realize that depending on the
station to which I am assigned, this may involve complete isolation of up to nine
months in groups of four to 60 people. Personnel work at terrestrial elevations as
high as 12,000 feet (3,600 meters) at temperatures as low as –123 degrees
Fahrenheit (-86 degrees Celsius). I understand that the nature of the Antarctic
environment, with its potential hazards and extreme remoteness from major medical
facilities, makes stringent medical histories and physical examination screening
mandatory to ensure freedom from any disability which might imperil health, restrict
activity, or create a burden for one’s associates in Antarctica.

NSF Form 1428-A Page 1 of 2
OMB CONTROL NUMBER 3145-0177: Expires SEP 2010

(APR 2002)

Request for Waiver of USAP Medical Screening Criteria

4. I have been informed that:
a.

I have a condition which disqualifies me for assignment/travel to Antarctica.

b.

This disqualifying condition is: __________________________________

_______________________________________________________________
c. This condition is subject to waiver consistent with USAP Medical Standards
and National Science Foundation policy.
5. Knowing and understanding the above, I request the National Science Foundation
to waive the requirements of the USAP Medical Standards with regard to the above
described disqualification to enable me to travel/be assigned to Antarctica. I agree to
accept and comply with any and all conditions that may be imposed upon any waiver
issued as a result of this request. For and in consideration of receiving such waiver,
and for and on behalf of myself, my personal representatives, heirs and assigns, I
release and discharge the U.S., its agents, servants, or employees, including but not
limited to the National Science Foundation, the Department of Defense and its
agencies, their agents, servants, or employees, whether military or civilian, and
where applicable, Raytheon Polar Services Company, its agents, servants and
employees from any and all claims for property damage, personal injury, or death
resulting directly or indirectly from issuance of this waiver of the above described
disqualifying condition.
I, ______________________, do hereby certify on this ______ day of ___________
20____ that I am the individual about whom this Request for Waiver of U. S. Antarctic
Program Medical requirements and release of harm pertains. I fully understand this
document and agree to its terms.
In the CITY or COUNTY OF: _______________________________________
STATE OF: __________________ on this _____ day of _____________ 20____
____________________________, who is known to me to be the person named
herein and who did appear before me and signed the foregoing Request for Waiver
and acknowledged to me that he/she voluntarily executed the same.

__________________________
NOTARY PUBLIC (signature)

____________
(date)

My Commission expires ______________________________
(Signature)

NSF Form 1428-A Page 2 of 2
OMB CONTROL NUMBER 3145-0177: Expires SEP 2010

(APR 2002)